On Distant Battlefields, Survival Odds Rise Sharply

By

Alan Cullison

April 2, 2010

KANDAHAR, Afghanistan—Under a dusty hospital tent where doctors yell over the roar of jet engines, Dr. John York studied an electronic image of a blood vessel in the neck of a soldier wounded by an improvised bomb. It looked like a balloon ready to pop. Too delicate to operate on directly. Dr. York would have to try a procedure that had rarely been attempted so close to a battlefield.

Using a sophisticated X-ray machine, he snaked a tube from an artery in the soldier's leg until it reached his neck. Dr. York threaded in a feathery device that popped open and blocked blood from the ballooning artery.

Today that soldier, Specialist Chancellor Alwin, is an outpatient at the army medical hospital in Washington. His only visible scars from the January procedure are a small one near his neck and another in his thigh. His wife, Samantha, says he suffers from moods swings and lingering nerve damage, "but we are thankful he is alive," she says.

Medical advancements have led to greater survivability of war wounds among U.S. troops in Afghanistan and Iraq, as well as greater complications in caring for survivors. WSJ's Alan Cullison reports from the 451st Air Expeditionary Wing medevac unit in Kandahar Province, Afghanistan. Photos by Kate Brooks.

Every war brings medical innovations, as horrific injuries force surgeons to come up with new ways to save lives. During the Civil War, doctors learned better ways to amputate limbs, and in World War I they developed the typhoid vaccine. World War II brought the mass use of penicillin, Korea and Vietnam the development of medical evacuation by helicopter.

The lessons of Iraq and Afghanistan, medical experts say, are still emerging. One legacy is new ways to control bleeding before soldiers lapse into comas or their vital organs shut down. Thanks to new clotting agents, blood products and advanced medical procedures performed closer to the battlefield, wounded American soldiers are now surviving at a greater rate than in any previous war fought by the U.S.

The rising survival rate, now touching 95% for those who live long enough to get medical treatment, is in turn introducing new problems caring for patients with serious and chronic injuries, including multiple amputations and brain damage. The cost of treating such lasting injuries will be borne by the U.S. medical system for decades to come.

On the medical front lines, however, military doctors often focus just on keeping wounded soldiers alive. In Afghanistan, troops are protected by new generations of armored vehicles, bulletproof vests and helmets that often keep them from getting killed outright in firefights. That leaves doctors and medics to face a dire range of war wounds—limbs mangled and severed by explosive devices, shrapnel and bullet wounds to the face and the neck, and unseen internal bleeding.

"If you can stop the bleeding, you gain time to save a life," says Sgt. Anthony Reich, the U.S. Air Force's equivalent of a paramedic, who flies into battle zones to retrieve the wounded and bring them to Kandahar air field for treatment. "Medical textbooks are being rewritten as we speak."

Dr. York, an interventional radiologist who usually performs surgery at the U.S. Naval Medical Center in Portsmouth, Va., is especially skilled at treating internal injuries. His type of surgery—using X-rays and imaging equipment to guide catheters through veins to perform micro-operations—is comparatively rare in emergency rooms. But in the cramped Kandahar hospital, it is critical to saving lives.

ENLARGE

A soldier wounded by an improvised bomb undergoes a CT scan at a battlefront hospital in Afghanistan.
Kate Brooks

When Specialist Alwin was wheeled in on a gurney with shrapnel in his neck, the soldier refused to lie down because doing so made it hard to breath, Dr. York recalls. Doctors performed a CT scan and were horrified by what they saw. Shrapnel had grazed one of the two vertebral arteries that fed his brain. The ballooning artery was leaking into his upper chest, closing his windpipe. It appeared to be just a matter of time before it would burst. That's when Dr. York performed the delicate operation.

Many of the cutting-edge techniques used here had been recommended by physicians years ago, but were never tested on a mass scale until the wars in Iraq and Afghanistan, says James Dunne, director of the U.S. Central Command's Joint Theater Trauma System at Bagram air base in Afghanistan. If Iraq was an early proving ground for methods, Afghanistan is the theater for perfecting them, he says.

Early in the Iraq war, medics supplemented old-fashioned gauze bandages with QuikClot, a clay kitty-litter-like substance manufactured by Z-Medica Corp. of Wallingford, Conn. When sprinkled into wounds, it absorbs water from blood and "stops bleeding like a clogged pipe," says Sgt. Reich, the Air Force medic.

ENLARGE

X-ray of the pelvis of a soldier injured in Kandahar Province by an IED reveals shrapnel and a broken femur.
Kate Brooks

But surgeons at battlefield hospitals often had to pick the gooey granules out of wounds, and the byproduct of the clotter sometimes left burns on flesh. Z-Medica subsequently developed QuickClot Combat Gauze—surgical gauze treated with organic material that helps blood coagulate quickly, doesn't burn the flesh, and "is easy to push down into crevices and is easily removed," Dr. Dunne says.

Dr. Dunne says another important change involves blood transfusions. Doctors used to pay little attention to the age of the blood used for massive transfusions, as long as it was within a stipulated shelf life. But now the emphasis is on fresh red-blood cells, which appear to carry more oxygen and clot faster.

As a result, the U.S. military has sped up blood delivery, Dr. Dunne says. Today blood is flown from the U.S. through the coalition's Al Udeid Air base in Qatar and delivered to field hospitals in Afghanistan three and a half days after it comes out of a donor's arm.

One of the most important innovations is a reemphasis on one of the oldest medical implements on the battlefield: the tourniquet. It was frowned upon in previous years because doctors feared it could cause long-term limb damage. Servicemen are now issued a Combat Action Tourniquet, dubbed CAT, made by Composite Resources, of Rock Hill, S.C.

Two CATs are now issued to every soldier. They are easy to use because each tourniquet has a black plastic lever that tightens it. Marines often go on foot patrols with tourniquets loosely strapped high on their thighs, so they can begin cranking right away if a foot is blown off.

Desperate Times

The military's nerve center for innovations is the Joint Theater Trauma System, set up by the Defense Department in San Antonio, Texas. It analyzes statistics on battlefield injuries to see what treatments are working. A research article from the trauma center was one reason tourniquets were issued en masse in October 2008, after a study suggested that mortality rates could be reduced dramatically if soldiers could strap on a tourniquet before arriving at the hospital.

Many new life-saving ideas come from the field, in hospitals like the shabby plywood-and-fabric one on the North Atlantic Treaty Organization military base at Kandahar airport. Kandahar, a city of about 450,000, is the Taliban's main stronghold in southern Afghanistan and the region that has seen the fiercest fighting since the U.S.-led invasion in 2001. Last July and August, as the insurgency intensified with the warmer weather, the hospital took in nearly 170 helicopter-evacuated patients a month.

Dr. York says his most useful work is controlling bleeding in smashed pelvises, where an array of blood vessels lie along the bone and can be easily ruptured. As other surgeons work on head and leg injuries, Dr. York shoots dye into the pelvis, and if the imaging equipment picks up any bleeding, he blocks the vessels through more catheter implants.

Dr. York was at the gym one Sunday morning in February when he got word that a helicopter was bringing in two soldiers from the nearby Arghandab Valley, both injured by an improvised explosive device.

One soldier, both legs blown off, was dead when the helicopter arrived. The other, a 23-year-old infantryman, was alive but bleeding badly from a gaping wound on his left side. A scan of his pelvis showed a splintered femur and a cluster of shrapnel in his thigh.

The helicopter medic had given him a strong dose of Ketamine, a powerful anesthetic mostly frowned on in the U.S. but which the military has lately used in Afghanistan because it seems to help soldiers feel indifferent to their wounds. On the gurney in the trauma bay, the soldier sang softly to himself while doctors discussed whether his leg would have to be amputated.

Dr. York shot dye into the soldier's arteries and under a scanner saw that all the vessels down to his foot were intact. The leg, he said, could be saved. In the operating tent, the surgeons cleaned the debris from his wounds. Dr. York put a nickel-and-titanium filter into one of his veins just below the heart to keep errant blood clots from flowing into his heart and lungs, which could kill him. "There—just like a screen in a screen door," he said, watching his work on a computer monitor. "He's safe for now."

Though wounds differ, patterns are discernible, says Capt. Anne Lear, the hospital's head nurse. Most time and energy is spent researching injuries from IEDs, the Taliban's weapon of choice. Ms. Lear says blast injuries usually fall into two categories: those that dismember soldiers on foot patrol, and less visible ones that soldiers suffer while riding in armored vehicles.

ENLARGE

Dr. John York, in glasses at left, works on the soldier. U.S. military doctors decided that the leg could be saved.
Kate Brooks

The men on foot patrols, she says, often lose both legs and one arm. The way we walk, with one arm usually swinging behind the body, often shields that arm from the blast, she says.

Armored vehicles, even if they hold together in a blast, get thrown into the air and slam around their occupants. Even those who are strapped in may bleed internally from broken arms and elbows, fractured spines and pelvises.

When Dr. York finished treating the young infantryman, the next patient was announced: A 22-year-old sergeant who had just shot himself in the head. There were clean entry and exit wounds in his temples.

His heart was beating steadily. Dr. York said it might be a freak head wound that is survivable. But a CT scan elicited a collective groan from the doctors. The bullet had passed through the center of his brain, blowing out his pituitary gland and damaging his brain stem. Bits of bone were dispersed through his skull.

"He knew right where to put the gun," said Dr. York.

Nurses wheeled the sergeant to a small space behind some blue curtains. Within half an hour, he had stopped breathing.

The last patient that day, a 31-year-old captain in the British infantry, the Royal Anglian Regiment, arrived late. On patrol that morning, he had stepped on an IED. The blast took off both legs, his right arm and all the fingers on his left hand, except his index finger.

The captain, Martin Driver, was sedated, the stumps of his limbs wrapped tightly in gauze and a pulse monitor fixed on his one remaining finger.

The medical staff gave him massive transfusions of blood products—plasma, red-blood cells, platelets, whole blood, and two doses of an experimental clotting agent. He lost most of it to bleeding. All told, he received about four times the volume contained in an average person.

By the following evening, his wounds finally appeared to be clotting.

Note to Readers:

The photograph of Capt. Martin Driver that ran with the story was removed because the image does not conform to our editors' guidance that we not publish photographs of the dead and dying without a compelling reason.

"If this had happened to him in the U.S. or anywhere else, they could not have kept him alive," said Dr. Tony Han, who watched over Capt. Driver that night. He kept the captain's blood pressure low to help the clotting process and protect against fatal bleeding. The wounded soldier's face and chest appeared eerily untouched by the blast. With his combed-back hair and pinkish complexion, he looked like an officer resting up before another patrol.

Just before midnight, a British medical crew arrived to put him on a plane back to England. The IED blast had thrown dust and debris into Capt. Driver's abdomen, where an infection was raging. His prospects for recovery were uncertain.

As they lifted him onto a stretcher, the captain's eyes fluttered. The British doctor spoke to him, although it was unclear whether he could hear. "I see you're blinking now, Martin," he said. "We're taking you back to Birmingham so that your family can see you. We will keep you comfortable the whole way."

They took along another box of blood for transfusions, along with a medical chart that described his transfer to England as a "mission of compassion." Capt. Driver died on March 15.

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